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HEALTH CARE POWER OF ATTORNEY
NOTE: YOU SHOULD USE THIS DOCUMENT TO NAME A PERSON AS YOUR HEALTH CARE
AGENT IF YOU ARE COMFORTABLE GIVING THAT PERSON BROAD AND SWEEPING POWERS
TO MAKE HEALTH CARE DECISIONS FOR YOU. THERE IS NO LEGAL REQUIREMENT THAT
ANYONE EXECUTE A HEALTH CARE POWER OF ATTORNEY.
EXPLANATION: You have the right to name someone to make health care decisions for you when you cannot
make or communicate those decisions. This form may be used to create a health care power of attorney, and meets
the requirements of North Carolina law. However, you are not required to use this form, and North Carolina law
allows the use of other forms that meet certain requirements. If you prepare your own health care power of attorney,
you should be very careful to make sure it is consistent with North Carolina law.
This document gives the person you designate as your health care agent broad powers to make health care decisions
for you when you cannot make the decision yourself or cannot communicate your decision to other people. You
should discuss your wishes concerning life-prolonging measures, mental health treatment, and other health care
decisions with your health care agent. Except to the extent that you express specific limitations or restrictions in this
form, your health care agent may make any health care decision you could make yourself.
This form does not impose a duty on your health care agent to exercise granted powers, but when a power is
exercised, your health care agent will be obligated to use due care to act in your best interests and in accordance
with this document.
This Health Care Power of Attorney form is intended to be valid in any jurisdiction in which it is presented, but
places outside North Carolina may impose requirements that this form does not meet.
If you want to use this form, you must complete it, sign it, and have your signature witnessed by two qualified
witnesses and proved by a notary public. Follow the instructions about which choices you can initial very carefully.
Do not sign this form until two witnesses and a notary public are present to watch you sign it. You then should give
a copy to your health care agent and to any alternates you name. You should consider filing it with the Advance
Health Care Directive Registry maintained by the North Carolina Secretary of State:
http://www.nclifelinks.org/ahcdr/
1.Designation of Health Care Agent.
I, .................., being of sound mind, hereby appoint the following person(s) to serve as my health care agent(s) to act
for me and in my name (in any way I could act in person) to make health care decisions for me as authorized in this
document. My designated health care agent(s) shall serve alone, in the order named.
A. Name: ____________________ Home Telephone: ______________
Home Address: ____________________ Work Telephone: _______________
_____________________________________ Cellular Telephone: _______________
B. Name: ____________________ Home Telephone: _______________
Home Address: ____________________ Work Telephone: _______________
_____________________________________ Cellular Telephone: _______________
C. Name: ____________________ Home Telephone: _______________
Home Address: ____________________ Work Telephone: _______________
_____________________________________ Cellular Telephone: _______________
Any successor health care agent designated shall be vested with the same power and duties as if originally named as
my health care agent, and shall serve any time his or her predecessor is not reasonably available or is unwilling or
unable to serve in that capacity.
2.Effectiveness of Appointment.
My designation of a health care agent expires only when I revoke it. Absent revocation, the authority granted in this
document shall become effective when and if one of the physician(s) listed below determines that I lack capacity to
make or communicate decisions relating to my health care, and will continue in effect during that incapacity, or until
my death, except if I authorize my health care agent to exercise my rights with respect to anatomical gifts, autopsy,
or disposition of my remains, this authority will continue after my death to the extent necessary to exercise that
authority.
1. ____________________ (Physician)
2. ____________________ (Physician)
If I have not designated a physician, or no physician(s) named above is reasonably available, the determination that I
lack capacity to make or communicate decisions relating to my health care shall be made by my attending physician.
3.Revocation.
Any time while I am competent, I may revoke this power of attorney in a writing I sign or by communicating my
intent to revoke, in any clear and consistent manner, to my health care agent or my health care provider.
4.General Statement of Authority Granted.
Subject to any restrictions set forth in Section 6 below, I grant to my health care agent full power and authority to
make and carry out all health care decisions for me. These decisions include, but are not limited to:
A. Requesting, reviewing, and receiving any information, verbal or written, regarding my physical or mental
health, including, but not limited to, medical and hospital records, and to consent to the disclosure of this
information.
B. Employing or discharging my health care providers.
C. Consenting to and authorizing my admission to and discharge from a hospital, nursing or convalescent home,
hospice, long-term care facility, or other health care facility.
D. Consenting to and authorizing my admission to and retention in a facility for the care or treatment of mental
illness.
E. Consenting to and authorizing the administration of medications for mental health treatment and
electroconvulsive treatment (ECT) commonly referred to as "shock treatment."
F. Giving consent for, withdrawing consent for, or withholding consent for, X-ray, anesthesia, medication,
surgery, and all other diagnostic and treatment procedures ordered by or under the authorization of a licensed
physician, dentist, podiatrist, or other health care provider. This authorization specifically includes the power
to consent to measures for relief of pain.
G. Authorizing the withholding or withdrawal of life-prolonging measures.
H. Providing my medical information at the request of any individual acting as my attorney-in-fact under a
durable power of attorney or as a Trustee or successor Trustee under any Trust Agreement of which I am a
Grantor or Trustee, or at the request of any other individual whom my health care agent believes should have
such information. I desire that such information be provided whenever it would expedite the prompt and
proper handling of my affairs or the affairs of any person or entity for which I have some responsibility. In
addition, I authorize my health care agent to take any and all legal steps necessary to ensure compliance with
my instructions providing access to my protected health information. Such steps shall include resorting to any
and all legal procedures in and out of courts as may be necessary to enforce my rights under the law and shall
include attempting to recover attorneys' fees against anyone who does not comply with this health care power
of attorney.
I. To the extent I have not already made valid and enforceable arrangements during my lifetime that have not
been revoked, exercising any right I may have to authorize an autopsy or direct the disposition of my remains.
J. Taking any lawful actions that may be necessary to carry out these decisions, including, but not limited to: (i)
signing, executing, delivering, and acknowledging any agreement, release, authorization, or other document
that may be necessary, desirable, convenient, or proper in order to exercise and carry out any of these powers;
(ii) granting releases of liability to medical providers or others; and (iii) incurring reasonable costs on my
behalf related to exercising these powers, provided that this health care power of attorney shall not give my
health care agent general authority over my property or financial affairs.
5.Special Provisions and Limitations.
(Notice: The authority granted in this document is intended to be as broad as possible so that your health care agent
will have authority to make any decisions you could make to obtain or terminate any type of health care treatment or
service. If you wish to limit the scope of your health care agent's powers, you may do so in this section. If none of
the following are initialed, there will be no special limitations on your agent's authority.)
A. Limitations about Artificial Nutrition or Hydration: In
exercising the authority to make health care decisions on
my behalf, my health care agent:
___________ shall NOT have the authority to withhold artificial
(Initial) nutrition (such as through tubes) OR may exercise that
authority only in accordance with the following special
provisions:
___________________________________________________________
___________________________________________________________
___________ shall NOT have the authority to withhold artificial
(Initial) hydration (such as through tubes)OR may exercise that
authority only in accordance with the following special
provisions:
___________________________________________________________
___________________________________________________________
NOTE: If you initial either block but do not insert any
special provisions, your health care agent shall have NO
AUTHORITY to withhold artificial nutrition or hydration.
___________ B. Limitations Concerning Health Care Decisions. In exercising
(Initial) the authority to make health care decisions on my behalf,
the authority of my health care agent is subject to the
following special provisions: (Here you may include any
specific provisions you deem appropriate such as: your
own definition of when life-prolonging measures should be
withheld or discontinued, or instructions to refuse any
specific types of treatment that are inconsistent with
your religious beliefs, or are unacceptable to you for
any other reason.)
___________________________________________________________
___________________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
___________ C. Limitations Concerning Mental Health Decisions. In
(Initial) exercising the authority to make mental health decisions
on my behalf, the authority of my health care agent is
subject to the following special provisions: (Here you
may include any specific provisions you deem appropriate
such as: limiting the grant of authority to make only
mental health treatment decisions, your own instructions
regarding the administration or withholding of
psychotropic medications and electroconvulsive treatment
(ECT), instructions regarding your admission to and
retention in a health care facility for mental health
treatment, or instructions to refuse any specific types
of treatment that are unacceptable to you.)
___________________________________________________________
___________________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
___________ D. Advance Instruction for Mental Health Treatment. (Notice:
(Initial) This health care power of attorney may incorporate or be
combined with an advance instruction for mental health
treatment, executed in accordance with Part 2 of Article
3 of Chapter 122C of the General Statutes, which you may
use to state your instructions regarding mental health
treatment in the event you lack capacity to make or
communicate mental health treatment decisions. Because
your health care agent's decisions must be consistent
with any statements you have expressed in an advance
instruction, you should indicate here whether you have
executed an advance instruction for mental health
treatment):
___________________________________________________________
___________________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
___________ E. Autopsy and Disposition of Remains. In exercising the
(Initial) authority to make decisions regarding autopsy and
disposition of remains on my behalf, the authority of my
health care agent is subject to the following special
provisions and limitations. (Here you may include any
specific limitations you deem appropriate such as:
limiting the grant of authority and the scope of
authority, or instructions regarding burial or
cremation):
___________________________________________________________
___________________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
6.Organ Donation.
To the extent I have not already made valid and enforceable arrangements during my lifetime that have not been
revoked, my health care agent may exercise any right I may have to:
___________ donate any needed organs or parts; or
(Initial)
___________ donate only the following organs or parts:
(Initial)
________________________________________________________________
NOTE: DO NOT INITIAL BOTH BLOCKS ABOVE.
___________ donate my body for anatomical study if needed.
(Initial)
___________ In exercising the authority to make donations, my health care
(Initial) agent is subject to the following special provisions and
limitations: (Here you may include any specific limitations
you deem appropriate such as: limiting the grant of authority
and the scope of authority, or instructions regarding gifts of
the body or body parts.)
________________________________________________________________
________________________________________________________________
________________________________________________________________
NOTE: DO NOT initial unless you insert a limitation.
NOTE: NO AUTHORITY FOR ORGAN DONATION IS GRANTED IN THIS INSTRUMENT
WITHOUT YOUR INITIALS.
7.Guardianship Provision.
If it becomes necessary for a court to appoint a guardian of my person, I nominate the persons designated in Section
1, in the order named, to be the guardian of my person, to serve without bond or security. The guardian shall act
consistently with G.S. 35A-1201(a)(5).
8.Reliance of Third Parties on Health Care Agent.
A. No person who relies in good faith upon the authority of or any representations by my health care agent shall
be liable to me, my estate, my heirs, successors, assigns, or personal representatives, for actions or omissions
in reliance on that authority or those representations.
B. The powers conferred on my health care agent by this document may be exercised by my health care agent
alone, and my health care agent's signature or action taken under the authority granted in this document may
be accepted by persons as fully authorized by me and with the same force and effect as if I were personally
present, competent, and acting on my own behalf. All acts performed in good faith by my health care agent
pursuant to this power of attorney are done with my consent and shall have the same validity and effect as if I
were present and exercised the powers myself, and shall inure to the benefit of and bind me, my estate, my
heirs, successors, assigns, and personal representatives. The authority of my health care agent pursuant to this
power of attorney shall be superior to and binding upon my family, relatives, friends, and others.
9.Miscellaneous Provisions.
A. Revocation of Prior Powers of Attorney. I revoke any prior health care power of attorney. The preceding
sentence is not intended to revoke any general powers of attorney, some of the provisions of which may relate
to health care; however, this power of attorney shall take precedence over any health care provisions in any
valid general power of attorney I have not revoked.
B. Jurisdiction, Severability, and Durability. This Health Care Power of Attorney is intended to be valid in any
jurisdiction in which it is presented. The powers delegated under this power of attorney are severable, so that
the invalidity of one or more powers shall not affect any others. This power of attorney shall not be affected
or revoked by my incapacity or mental incompetence.
C. Health Care Agent Not Liable. My health care agent and my health care agent's estate, heirs, successors, and
assigns are hereby released and forever discharged by me, my estate, my heirs, successors, assigns, and
personal representatives from all liability and from all claims or demands of all kinds arising out of my health
care agent's acts or omissions, except for my health care agent's willful misconduct or gross negligence.
D. No Civil or Criminal Liability. No act or omission of my health care agent, or of any other person, entity,
institution, or facility acting in good faith in reliance on the authority of my health care agent pursuant to this
Health Care Power of Attorney shall be considered suicide, nor the cause of my death for any civil or criminal
purposes, nor shall it be considered unprofessional conduct or as lack of professional competence. Any
person, entity, institution, or facility against whom criminal or civil liability is asserted because of conduct
authorized by this Health Care Power of Attorney may interpose this document as a defense.
E. Reimbursement. My health care agent shall be entitled to reimbursement for all reasonable expenses incurred
as a result of carrying out any provision of this directive.
By signing here, I indicate that I am mentally alert and competent, fully informed as to the contents of this
document, and understand the full import of this grant of powers to my health care agent.
This the ..... day of .............., 20.....
.........................(SEAL)
I hereby state that the principal, ..............., being of sound mind, signed (or directed another to sign on the principal's
behalf) the foregoing health care power of attorney in my presence, and that I am not related to the principal by
blood or marriage, and I would not be entitled to any portion of the estate of the principal under any existing will or
codicil of the principal or as an heir under the Intestate Succession Act, if the principal died on this date without a
will. I also state that I am not the principal's attending physician, nor a licensed health care provider or mental health
treatment provider who is (1) an employee of the principal's attending physician or mental health treatment provider,
(2) an employee of the health facility in which the principal is a patient, or (3) an employee of a nursing home or any
adult care home where the principal resides. I further state that I do not have any claim against the principal or the
estate of the principal.
Date: ________________________ Witness: __________________________
Date: ________________________ Witness: __________________________
................ COUNTY, ................. STATE
Sworn to (or affirmed) and subscribed before me this day by .........................
(type/print name of signer)
.........................
(type/print name of witness)
.........................
(type/print name of witness)
Date: ______________________________ ________________________________________
(Official Seal) Signature of Notary Public
_________________________, Notary Public
Printed or typed name
My commission expires: _________________
